Table: Medline "Internet" articles:

1991 - 1

1992 - 8

1993 - 30

1994 - 89

1995 - 215

1996 - 412

1997 - 755

1998 - 1363

1999 - 1938

2000 - 2251

2001 - 3781 (extrapolated)

Total 10, 843

The first description of the Internet in the Medline-searchable medical literature appeared in this journal Administrative Radiology in August of 1991. A framed copy of that article by J. Hankins entitled simply "The Internet"(1) hangs in the Library of Congress. Odd then to reflect on the fact that at this writing Administrative Radiology has no website.

The first author grew up in a household without television, the steady stream of library books and interesting people entering the house seeming to validate the unusual parental decision to eschew television in a small town in upstate New York where a TV antenna sprouted from every other rooftop in town. Similarly to our knowledge this is the only member of the community of medical journals that has not yet spouted a website.

You can sense the productive tension here: The journal that started discussions of the Internet in medicine is not actually on the Internet ten years later! The journal that prides itself in individuality - that once contained an article by nonradiologist Ronald Reagan - clearly marches to the beat of a different drummer.

That individualistic approach is wonderfully instructive and perhaps can help us set this present article apart from the 10,000+ other Medline searchable articles containing the word "Internet"!

Like the tension in a good novel there is mystery here: A specific mystery of the Internet and Administrative Radiology, and the general mystery of the Internet and medicine.

And along the way we will learn something about "personal relationships" in medicine. Rick Martinez the publisher of Administrative Radiology fears that a website would degrade the personal relationships which are so important to running the journal. Gone would be the shake-your-hand-look-you-in-the-eye personal exchange of feelings, persona, and character--always a key element in human interactions-- replaced by words and images on a screen. Pixels rather than hugs, people reduced to digital elements 1's and 0's, nothing any longer accurately reflecting that analog life form - the human being.

Presence on the Internet need not lead to any of these distancing effects. Zina Munoz who heads the Renal-Tech computer donation project (2) involved in "wiring" the health establishment in poorer countries also cherishes personal relationships in medicine.The construct behind Renal-Tech is that personal relationships established during a single brief visit are maintained through continued interactions over the Internet. So a visit to Kosovo does not result in a transient upward blip in quality of medical life for those in the recipient country, but rather a sustained increase to a new more positive steady state achieved through a constant stream of online interactions that transcend distance and cultural differences.

Taking the long view, it was never the intention or prediction that technology would take away from human interaction, from the human experience, but rather that it would increase and enhance it. The Internet and cyberMedicine are forces for good in medicine.

The healing process central to medicine requires warmth and communication. Originally machines were cold and uncommunicative. Today's machines are warm and connected. A laptop in "sleep" mode may have a temperature similar to a human being. Heat generation is the limiting factor in the further miniaturization of high technology devices, so as they evolve they will remain warm.

Analogies aside, the Internet in medicine allows the writing of individual patients, parents, and physicians to have a global impact that could not be achieved by any other means. So rather than having dehumanizing and distancing effects, Internet resources make us more human and more connected.

Anthropologist Ray Birdwhistell has estimated that only 35% of human communication is words (3). The rest is gesture, body language, inflection, facial expressions, pheromones etc. (Birdwhistell noted 23 different "meaningful" eyebrow positions!). The assertion "You can't hug someone over the Internet."is technically untrue: sites such as http://www.postcards.org and others offer the possibility of conveying a greater variety of hugs than one could ever think of in person.

The possibility of total immersion in the virtual experience is getting closer (4). Improvements in technology and bandwidth as applied to videoconferencing and virtual reality will make people feel increasingly connected. Better buffering and connection speed in Internet video will improve synchrony and naturalness of audio and lip movements increasing the effectiveness of Internet psychotherapy and speech therapy.Images will be in 3D enhancing the performance of telesurgery and other visually intensive cyberMedicine activities.

Exactly when the "fully immersive Internet" will be arrive is a balance between two forces: improving technology and human being's increasing ability to detect ever more subtle differences between the real and the virtual world. In the early days of cinema at the beginning of the 1900s, people ran out of the theater when a train was coming right at the camera. This no longer happens because human beings have learned the difference between movie images and real trains. We have reached the point where virtual sound is almost indistinguishable from real sound, and we will eventually reach the same point with virtual sight, virtual touch, virtual smell etc. all of which will impact on cyberMedicine.

The fear of the Internet and cyberMedicine is largely a fear of the unknown. CyberMedicine is rapidly entering the realm of the "known" and probably represents a danger only to those who ignore it as a trend.

Many positive new technologies are factors propelling medicine toward cyberMedicine: genomics, proteomics, nanotechnology, robotic medicine, telemedicine, machine translation breakthroughs, the medical publishing revolution, and new 3D imaging techniques. Ray Kurzweil's prediction that in twenty years there will be flawless machine translation from one language into another (5) has enormous significance for human interactions in medicine.

The inevitability of the Internet/cyberMedicine revolution and the fact that it is mainly a change for the best mirrors the beneficial effects of technology in the world at large. For instance it may initially sadden the reader to know that In Australia, ornithologists have discovered that the country's so-called "mimic birds" are starting to use cell phone noises in place of their traditional mating calls (6). While shattering certain nostalgic feelings about bird songs, this transformation is not necessarily a bad thing. Birds with these singing abilities may have a selective advantage over others, and they represent the vanguard in the evolution of stronger productiveties between nature and machines.

And for those who sometimes see technology as leading a mad plunge into darkness it is interesting to consider the opposite possibility: It is technology that poet/singer Leonard Cohen is seeing as mankind's salvation in the song "The Great Event" when he has the synthesized Macintosh Text-to-Speech voice of Victoria say these words: "Next Tuesday, when the sun goes down, I will play the Moonlight Sonata backwards. This will reverse the effects of the world's mad plunge into suffering, for the last 200 million years."(7)

Art is not immune from the positive effects of technology. In May 2001 technology guru Ray Kurzweil unveiled the Aaron software program capable of creating museum-quality original paintings (8). Artist Harold Cohen taught the software program the nuances of his art little by little over thirty years and now it is being sold to the public for $19.95 US. Similar programs are being developed for poetry and music.

Music, poetry, art – in all these areas technology and the Internet appear to be poised to take man and womankind to new heights – so why not in medicine? All those things that we value in medicine can be even better in cyberMedicine, we just have to put up with some bumps in the road to get there!

So the mystery is solved: Medicine and the Internet, which in the beginning seemed to be competing forces incompatible with each other, are becoming cooperating partners in increasingly advanced human civilization. And Administrative Radiology will inevitably have a website (and this article is on the web as you read it). The first medical journal to have the concept is the last to join the celebration, but when that happens Administrative Radiology will be able to proudly state that one phase of the technological evolution of medicine is complete!

(Drs. Kim Solez and Sheila Moriber Katz are partners in the cyberMedicine joint venture http://www.cyber-medicine.org . Kim Solez and Michele Hales are respectively Director and Assistant Director of the cyberNephrology initiative of the National Kidney Foundation http://www.cybernephrology.org .)

References:

1.Hankins J. The Internet. Adm Radiol. 10(8):69-71, 1991 .

2.http://www.renal-tech.org

3. Birdwhistell, Ray. Kinesics and context: essays on body motion communication. Philadelphia: University of Penn. Press. 1970.

4. Kaplan K: A Virtual World of Sight, Sound and Even Smell Los Angeles Times Service http://www.iht.com/articles/10344.htm February 12, 2001

5. Kurzweil R: The Age of Spiritual Machines - When Computers Exceed Human Intelligence, Viking Penguin Press, 1999 .

6. Reaves J: Cell Phones: Unsafe at Any Speed. Time Magazine Jun. 12, 2001 http://www.time.com/time/health/article/0,8599,130210,00.html

7. Cohen L: The Great Event, More Best of Leonard Cohen, 1997 http://www.leonardcohen.com/

8. Kurzweil R: AARON: A product of Kurzweil cyberArt Technologies , 2001 http://devweb.kurzweilcyberart.com/ , http://www.scinetphotos.com/aaron.html